Repeated Misunderstanding of Concussions

A recent New York Times article entitled “FDA Approves First Blood Test to Detect Concussions”, dated February 14, 2018, touts a new blood test as being able to detect concussions or commonly known as Traumatic Brain Injuries (TBI) without the need for neuro-imaging tests such as MRI and CT scans. The authors of the article writes that the test, the Banyan Brain Trauma Indicator, can detect brain tissue damage or intracranial lesions caused by Traumatic Brain Injuries (TBI). The authors further state that the test “could eliminate the need for CT scans…” According to the article, the test works by measuring the levels of specific proteins, known as UCH-L1, and GFAP, that are released from the brain into blood and measured within 12 hours of the head injury (Traumatic Brain Injuries- TBI). Levels of these blood proteins can help predict which patients may have intracranial lesions visible by CT scan, and which won’t.

The critical word that we need to focus on according to the article is “lesions”. If this new blood test can only detect lesions, then it only rules out a very small portion of concussions or traumatic brain injuries (TBI). Concussions or Traumatic Brain Injuries (TBI) can occur without lesions or bleeds. In fact the majority of concussions Traumatic Brain Injuries (TBI) don’t lead to lesions or bleeding. The insidious nature of most Traumatic Brain Injuries (TBI) is the brain appears normal on CTs and MRIs since there usually is no bleeding or lesions. But, that does not mean that other parts of the brain, such as the internal network of axons, are not damaged as a result of Traumatic Brain Injuries (TBI).

Another reason this article is inaccurate is that CT scans are not used to detect lesions. They detect bleeding and fractures. CT scans are usually not sensitive enough to detect lesions in the brain. MRIs are commonly used to detect lesions. The protocol with most hospital emergency rooms with regard to Traumatic Brain Injuries (TBI) is to determine if there is bleeding in the brain with the use of CT scans. Most of the time when a patient goes to the emergency room due to Traumatic Brain Injuries (TBI), MRIs are not performed but only CTs.

The headline about detecting concussion is quite misleading. The role of the test is triage, to detect a subset of patients who have a higher likelihood of visible brain pathology on CT and should be closely examined in the acute setting. These patients may need surgery and are at higher risk for mortality. This type of screening is addressing the life or death aspect of TBI. It does not predict long-term outcome and would deem most concussed individuals “fine”. That creates a false sense of security and a misconception that injuries with a negative test are not significant. That may be true in terms of near-term need for neurosurgery and intensive care, but is absolutely not true for function over the long-term.

Additionally, this article undermines the truth about how concussions or Traumatic Brain Injuries (TBI) can occur. It further perpetuates a lot of misunderstanding about concussions and Traumatic Brain Injuries (TBI) in that it defines a concussion or Traumatic Brain Injuries (TBI) as an injury to the brain resulting in lesions. This definition is only partly true but leaves out a majority of concussions or Traumatic Brain Injuries (TBI) where lesions or bleeding do not occur. One of the most crucial parts of the brain, the billions of axons, the microscopic white matter communication pathways in the brain, are often permanently damaged despite the lack of lesions and bleeding. And, permanent damage to axons can have debilitating effect to a person’s psychiatric, behavioral and cognitive functioning.

The headline about detecting concussion is quite misleading. The role of the test is triage, to detect a subset of patients who have a higher likelihood of visible brain pathology on CT and should be closely examined in the acute setting. These patients may need surgery and are at higher risk for mortality. This type of screening is addressing the immediate life or death aspect of TBI. It does not predict long-term outcome and would deem most concussed individuals “fine”. That creates a false sense of security and a misconception that injuries with a negative test are not significant. That may be true in terms of near-term need for neurosurgery and intensive care, but is absolutely not true for function over the long-term.

As you watch the Super Bowl 2018, remember this…

This Sunday on February 4, 2018, one of the biggest events of the year will be on TV: The 52nd Super Bowl. Most of those watching the NFL probably do not know that “LII” is the Roman numeral for “52.” Yet, the NFL markets the Super Bowl by calling it Super Bowl LII. Why the use of Roman numerals? I’m sure there are lots of innocent explanations.

But one thing for sure is that the ancient Romans loved watching gladiators kill themselves. The thrill of strong men beating, maiming, and killing each other was probably the most exciting and thrilling event the Romans at the time offered their citizens. We are no different today. Super Bowl Sunday has become the biggest event to watch each year. Advertisement buys during the Super Bowl command the highest rates for any TV programming. Viewership is also the highest for any programming. According to Wikipedia, Super Bowl XLIX (49—be honest and tell me that you knew XLIX stood for 49), Super Bowl XLVIII (48), Super Bowl L (50), and Super Bowl LI (51) were the top all time most watched programs… except for the M*A*S*H final episode in 1983… 19 of the 20 most watched programs are the Super Bowls. How much do we admire and validate violence as a society? Are we still as barbaric as we were during the ancient gladiator times?

But, we watch this game at a comfortable distance… on TV. Do we have less courage now than those who watched the gladiators maim and kill each other? We choose to live in the denial of the insidious permanent Traumatic Brain Injury (TBI) that results from playing football. Never mind that, despite their brains appearing completely normal on modern tests as MRIs and CAT scans, Chronic Traumatic Encephalopathy (CTE as it as become known) has been found in the brains of more than 100 deceased NFL players who exhibited psychiatric and cognitive impairments while alive. Never mind that, the Center for Disease Control (CDC) has again and again informed the public that Traumatic Brain Injury (TBI) can occur even when there is no direct impact to the head. Whereas, in tackle football, impacts to the head are an integral part of the game.

For those of us who will watch the Super Bowl this coming Sunday, remember that the brain is a very soft structure housed inside a very rigid skull with sharp bony ridges that project into the brain. The brain consists of more than 100 billion long strands of axons that serve as the communication network for signals throughout the brain. These long strands of axons are so small that only ten can fit into a capillary blood vessel. And, capillaries are so small that our red blood cells must line up single-file to pass through.

When a player’s head crashes into another player, the brain is thrown about inside the rigid skull—the football helmet protects the skull, but does nothing to help protect the delicate brain inside. As the brain sloshes about inside the skull, the axons can be stretched, twisted, and sheared… the network is disrupted, leading to permanent brain damage. When the axons are sheared, communication within the brain breaks down. When this happens, our ability to think and process information is diminished… leading to impaired memory and judgment. The ability to control emotions and behavior are also affected which leads to sleep impairment and a host of psychological disorders such as depression and mood disorders, just to name a few. Unlike broken bones, skin cuts, or liver damage… The human body does not repair broken and sheared axons. This damage causes a chronic condition of cognitive impairment that can debilitate a person’s life. It can destroy a person’s ability to think. It can change their personality. This brain damage can affect relationships with family and friends. And, it can destroy the ability to make a living.

The Most Common Defense in Mild Traumatic Brain Injury Cases

We see the most common defense in mild traumatic brain injury cases time and time again. Namely, the CT and MRI brain scans do not reveal any abnormality, or trauma related injuries, in the Plaintiff’s brain. Therefore there is no serious or permanent brain injury suffered by Plaintiff. After a concussion, the medical protocol is to perform imaging of the brain to determine if there is any bleeding that requires emergency medical intervention. For instance, take the case of Natasha Richardson. She suffered a concussion that led to an epidural hematoma. This required emergent medical treatment to alleviate the pressure buildup in the brain that follows such an injury since there is no space in the brain for the excess blood to be stored. Such a hematoma would be readily visible in a CT scan, which is the most common brain imaging scan done following a concussion. While a CT or MRI scan may reveal bleeds and other gross abnormalities, neither will rule out axonal damage or other damage to the brain such as Chronic Traumatic Encephalopathy (CTE).

The insurance companies and their lawyers continue to perpetuate this false and now outdated interpretation of brain scans following mild traumatic brain injury cases.

Most, if not all, leading brain injury experts agree that normal brain scans, from a CT or MRI, do not eliminate the possibility of a serious brain injury.
Researchers of Chronic Traumatic Encephalopathy (CTE) commonly find CTE where brain scans from MRIs and CTs revealed no evidence of brain damage. Yet, other, more detailed, testing is available. Diffusion Tensor Imaging (DTI) studies routinely reveal evidence of axonal damage, also known as shearing white matter injury, after MRI and CT scans showed no injury to the brain.

The understanding that serious brain injuries occur despite the normal radiological findings, from MRI and CT scans, is widely known. This is not information available only to an elite and small circle of scientist and doctors, but is well circulated in the news, medical journals and scientific publications for the past several years. Yet, the insurance companies seek to perpetuate the old myth. Their lawyers retain the same usual suspects of “experts” over and over again to mislead our juries using outdated and false medical and scientific information. This is tantamount to perpetuating a fraud upon the court.

This past Sunday, 60 Minutes aired a feature interview of Ann McKee, MD, a leading neuropathologist testing brains for Chronic Traumatic Encephalopathy (CTE), “which so far can only be confirmed by brain autopsies.” CTE has been discovered in brains of athletes and veterans despite normal findings on MRI and CT scans. Dr. McKee calls CTE an invisible injury since “the effects on the brain that lead to CTE are not readily seen on images.”

When a person’s head is subject to sudden movement, the brain can be injured even where there is no direct trauma to the brain. A whiplash injury to the spine can cause the brain to move and slam into the inside of the skull leading to axonal damage as well as coup contra coup injury. Axons, which are known as white matter, are often shorn (hence, white matter shearing injury or Diffuse Axonal Injury (“DAI”) due to the sudden movement of the brain, which stretches the delicate tissue of the brain. Unlike the shape and weight of an object that is designed so that its entire mass moves at the same speed (like a golf ball), the brain is an odd shaped organ that has no uniformity in weight and has a density slightly firmer than tofu. Hence when the brain is caused to move, different parts of the brain move at different speeds having a shearing effect.

Axons are the most fragile part of the brain due to their shape, size, and length. Axons are microscopically thin and long, and are so small that ten (10) axons can fit into one capillary of the brain. Capillaries are blood vessels that are typically 5-10 micrometers in diameter. (Capillaries are so small that red blood cells can only travel through them in single file.) Yet, despite their diminutive size, axons serve as the crucial neuro-transmission pathways of the brain, providing connections for signals to travel and communicate throughout the brain.

Because axons are too small to image with MRI and CT scans, these common scans cannot detect axonal damage. At this point, only Diffusion Tensor Imaging (DTI) of the brain can detect axonal damage. While this information is well known and undeniable in the scientific and medical communities, the insurance companies and their “experts” remain locked in time as to their outdated understanding that brain injuries can occur despite normal findings on brain MRI and CT scans. There is a nefarious reason for this. They can prevent DTIs from being performed by refusing to pay for this modern and available up to date medical testing. In so refusing, they can avoid responsibility when people suffer life long debilitating brain injuries by making them difficult to prove without such testing.


Looking Beyond CTE

In recent news there has been a lot of attention focused on Chronic Traumatic Encephalopathy (CTE). Every day, we learn more and more professional athletes (NFL, NHL, Professional Wrestling, Professional Soccer) that have suffered repeated concussions are now suffering disabling symptoms such as depression, sleep disorders, anxiety disorders, as well as memory and concentration problems (cognitive impairments).

Most of the well-publicized incidences involve NFL players. Increasingly, we hear of former NFL players that are suffering these symptoms in their 30’s, 40’s and 50’s. Some take their own lives in horrific acts of suicide. Others have even taken the lives of their family members before they commit suicide.

The common denominators are:
1. They were former professional athletes;
2. They suffered repeated concussions;
3. They began to suffer symptoms of cognitive decline and impairment and psychiatric issues while much younger than those who typically suffer overlapping symptoms due to Alzheimer’s.

Yet the media consistently fails to fully comprehend that:

1. Chronic Traumatic Encephalopathy (CTE) is only one possible outcome from suffering Traumatic Brain Injuries (TBI) such as concussive, or sudden acceleration/deceleration, forces to the brain. We know that professional athletes that play in the NFL or NHL are at great risks of suffering Traumatic Brain Injury (TBI).

2. The real and ultimate damage to the brain is often due to the brain suddenly moving back and forth (sudden acceleration and deceleration) within the skull, and not due to actual blows to the head, as most would have you believe or misunderstand.

3. Sudden acceleration and deceleration of the brain can cause debilitating symptoms of Traumatic Brain Injury (TBI) such as cognitive impairment and psychiatric issues without resulting in Chronic Traumatic Encephalopathy (CTE). It just happens that CTE is one of the more severe and identifiable consequences of Traumatic Brain Injury (TBI). The reason that CTE is more identifiable includes the findings of Tau protein within the brains of those suffering CTE.

4. We must stop thinking that Chronic Traumatic Encephalopathy (CTE) is the only permanent brain damage from sudden acceleration and deceleration of the brain. This violent movement can and often does cause mild Traumatic Brain Injuries (mTBI) by causing Diffuse Axonal Damage (DAI) or Traumatic Axonal Damage (TAI). Symptoms of depression, anxiety, sleep disorder, and cognitive impairments such as short term memory problems, concentration impairments and decision making impairments are often related to Diffuse Axonal Damage (DAI) or Traumatic Axonal Damage (TAI). A person can suffer Diffuse Axonal Damage (DAI) or Traumatic Axonal Damage (TAI), and all of the resulting debilitating effects, without ever suffering from CTE.

5. Trying to understand why some former professional athletes suffer Traumatic Brain Injury (TBI) and wind up with Chronic Traumatic Encephalopathy (CTE), while others that play the same sport do not, is like trying to understand why everyone that smokes does not develop cancer. It is a pointless exercise and basically impossible due to a myriad of factors, including genetics, the exact types of concussions, the proximity of repeated concussions to each other, the nature and location of the resulting lesions, etc.

Many articles about CTE question whether psychiatric and/or cognitive impairment is due to CTE or other possibilities such as Alzheimer’s Disease. In order to determine whether cognitive impairments and/or psychiatric issues are causally related to TBI or Alzheimer’s, we need only consider the age of the athlete. Approximately 95% of people who suffer from Alzheimer’s are 65 and older. The fact that these athletes are significantly younger when they start to suffer symptoms should rule out Alzheimer’s. But given that athletes have often been playing Junior High, H.S., college, and professional football (15-20 years on average) and have suffered multiple concussions along the way should conclusively rule out Alzheimer’s.

It’s silly to consider Alzheimer’s as a possible explanation for those suffering TBI and its sequelae, even in those cases that do not result in CTE.

Concussion Fears Awakening within the NFL

On Wednesday this past week, A.J. Tarpley of the Buffalo Bills, announced that he was retiring from the NFL. What is more surprising is that he is only 23 years old. Tarpley, a linebacker for the Bills, gave the reason for this retirement as concerns for his long term health due to repeated concussions aka known as mild traumatic brain injury. He is the youngest player to retire from the NFL. Chris Borland, of the San Francisco 49ers also left recently after one season due to his fear of long-term brain damage from mild traumatic brain injury aka concussions leading to cognitive deficits and impairments. Hussain Abdullah retired in March of this year after suffering several concussions (mild traumatic brain injuries) in his 7 years with the NFL. Chronic Traumatic Encephalopathy (C.T.E.), a brain disease with severe cognitive impairments resulting from repeated mild traumatic brain injuries aka concussions, has been detected in the brains  of several retired players including quarterbacks like Ken Stabler of the Raiders. When asked for his comment about the sport and it’s dangers of lasting brain damage, Commissioner Goodell stated: “If I had a son, I’d love to have him play the game of football. He also said: “There’s risk in life. There’s risk in sitting on the couch.”

Helping our Community of Clients

A few weeks ago we received a call from one of our former clients who had recently received a notice to appear in court from his landlord. Mr. B. has been living with his family in their Queens apartment for 15 years since they arrived in the U.S. and called our office very worried about the possibility of having to uproot them. His landlord brought an action against him in Queens Housing Court to compel Mr. B to surrender possession of his apartment based on his lease having expired and their unwillingness to renew it. One of our paralegals did some research on housing law, accompanied the client to his hearing, and was able to help Mr. B come to an agreement with his landlord and remain in his apartment.

One of the most important things here at NL is that our clients, and even former clients, know their rights. We strive, not only to fight for our clients, but also to help them navigate other hurdles that may arise, sometimes as a result of their case.

We also make it a point to maintain open communication with our clients, and former clients. They trust us to have their best interests at heart. Our client community knows we have their back.

Functional MRI (FMRI)

FMRI has been around for many years now. It is no longer experimental. Yet, it is our opinion that the insurance industry and their legions try to keep the technology from becoming mainstream in investigating brain dysfunction and other diseases.

FMRI shows certain areas of the brain ‘lighting up’ during activity controlled by corresponding areas. FMRI can be used to detect inactivity as well. Inactivity where we would expect to see “lighting up” can represent physiological damage to that part of the brain. FMRI is sensitive to the functions of the brain whereas conventional MRIs only investigate structural damage to the brain, albeit on a very superficial level. Conventional MRIs will usually not detect axonal damage; hence the need for DTI (Diffuse Tensor Imaging) MRIs that measure deviations in water diffusion along the axons to detect structural damage to their myelin sheaths.

With most mild Traumatic Brain Injury (mTBI), the patient complains of clinical symptoms such as headaches, dizziness, concentration difficulty, memory impairment, anxiety, depression and sleep disorder after a traumatic event and yet there is no radiological proof of the brain damage. The typical neurologist sends the patient for a conventional CT or MRI to see if there are any bleeds or lesions. When the MRI comes back normal, the neurologist diagnoses a concussion and explains that the patient is experiencing Post Concussion Syndrome (PCS) and that he or she will get better within a few months. Some patients continue to suffer from ongoing cognitive deficits (e.g. concentration, memory, reading), emotional irregularity (e.g. depression, anxiety), physical symptoms (e.g. headaches, sleep disorder, dizziness, nausea, syncope, light sensitivity) and other sensorial deficits (e.g. smell, taste) for an indefinite period of time This leads to their lives falling apart. They can no longer function at work. They can no longer engage with their friends and family.

So the patient continues to experience and complain of clinical symptoms but the neurologist has exhausted his or her conventional toolbox. Some more contemporary educated neurologists will send their patient for a NeuroPsychological Evaluation (NPE). But an NPE is still a clinical evaluation, although a much more sensitive psychometric standardized test to measure brain functions than a Gross Mental Status exam.

In a lawsuit to recover damages for a mild Traumatic Brain Injury, the defense and insurance industry typically defend by saying that the patient is purposefully answering the NPE incorrectly as part of their malingering (faking) and secondary gain (money) motives. These defenses can be convincing to a conservative and skeptical jury.

Therefore, without further radiological proof or neuro-imaging, the jury may be fooled into believing that the Plaintiff did not suffer mild Traumatic Brain Injury (MTBI).

Two types of sensitive neuro-imaging tests can help in the investigation of brain damage in mild TBI cases.

The first type is structural — to see if there is damage, such as axonal damage that cannot be seen in conventional MRIs or CTs. DTI is the most sensitive study to assess axonal damage — which is probably present in 99% of mild Traumatic Brain Injury (mTBI) cases.

The second type of neuro-imaging is functional – to see if parts of the brain are functioning normally. PETs, FMRIs, and qEEG are the neuro-imaging functional diagnostic tests used to assess brain functions.

Of course, these tests are expensive and the greedy insurance companies want these tests to stay out of mainstream evaluations since they will further corroborate clinical symptoms and allow for more treatment. Most scientists that are not beholden to insurance companies know that there is so much about the brain we do not yet understand. They realize that a brain that looks normal on conventional imaging studies in a patient that can pass a Gross Mental Status exam may still be seriously injured and cause a host of clinical problems that can have a devastating effect to the person’s life.

Hidden Brain Injury Dangers in Pee Wee Football

Recently, a lot of attention has been given to Traumatic Brain Injuries (TBI) occurring in professional sports such as the NFL and NHL as well college level football. This past year, there have been numerous deaths, though not all related to Traumatic Brain Injury (TBI), from playing high school football. It is quite ignorant of us: the doctors, the lawyers and those leaders and administrators that are involved with tackle football leagues for younger players all the way down to the Pee Wee level, to believe that the dangers of brain injury are not relevant to younger players since there is less force involved.

In 2009, the chief neuropathologist at Boston University, who has been leading the investigation into Chronic Traumatic Encephalopathy (CTE) – a condition caused by repeated concussions that lead to brain tissue death – among professional athletes including those in the NFL and NHL, said that injuries to developing brains can have a far more detrimental effect than injuries to fully developed adult brains.

This means that a child who plays tackle football at the Pee Wee Level (ages 8-12) can suffer a more serious brain injury than an adult since the child’s brain is still developing.

We, at Nguyen Leftt, have always believed that the main cause of Traumatic Brain Injuries cannot be prevented by a football helmet. While the helmet may protect the player’s face and skull from trauma, it cannot protect the brain from the sudden acceleration and deceleration force attendant in violent contact sports such as tackle football and hockey.

We also believe that giving a child a helmet and other protective gear will give the child a false sense of belief that he is protected from traumatic brain injury. This false sense of protection will allow him to think he can hit harder than he would without a helmet. This is the added danger in the sport of tackle football. Not only is tackle football an inherently dangerous activity, the requirement of wearing a helmet ironically increases the danger.

Another hidden danger that we at Nguyen Leftt see is that the weight of a heavy football helmet on a boy’s head adds to the speed of the sudden acceleration and deceleration of the brain. If we are to think of the spine as a whip and the tip of the whip is the head. The speed of the whip is fastest at the tip- the head. Now add weight to the tip/head and the tip/head moves faster during the whiplash movement of the spine. It’s common physics Force x Mass = Velocity. Increase the mass and the speed/velocity increases.

We believe that neither the parents nor child players are educated or warned about the inherent dangers of tackle football and that no helmet will protect from traumatic brain injuries. In the case of our client, who was playing Pee Wee tackle football at the time he suffered a severe concussion, he was wearing full protective gear. When we looked at the website of the manufacturer of the helmet he was wearing at the time he suffered his severe concussion, what we found out was before you can enter the website, a window pops up exclaiming:  “NO HELMET SYSTEM CAN PROTECT YOU FROM SERIOUS BRAIN AND/OR NECK INJURIES INCLUDING PARALYSIS OR DEATH. TO AVOID THESE RISKS, DO NOT ENGAGE IN THE SPORT OF FOOTBALL.”

Among other thoughts, we at Nguyen Leftt believe that leagues allowing young children with developing brains to engage in a sport that even the helmet manufacturer acknowledges are inherently dangerous must be held responsible whenever a child suffers an injury from engaging in tackle football. These leagues must warn and educate all parents and children of the inherent dangerous nature of tackle football.

Moreover, we think that a warning posted on a website of manufacturers who profit from selling helmets to tens of thousands of children is not sufficient to advise parents and children of the “protective gears” inability to protect our childrens’ brains.